62 WILLSON ST - BUILDING INSPECTION ( JZI The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
`f Massachusetts State Building Code, 780 CMR, 7"edition Namn
e yi' Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a lks*mwk I11
One- or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION l:SITE INFORMATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
4irc s�J s�
1.I a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
. I CS()-0 S'7
Name(Print Address for Service:
55
y a� 7YZ- A 3
ignature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': /Hvd e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�• , License Number Expiration Date .
N.4mc of CSL- Holder List CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Numtv_r
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
,Print Name
Signature of Owner or Authorized Agent Date
Si ned under the ains and enalties of (u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110,115, respectively.
2. When substantial work is planned,provide the information below:
Total Floors area(Sq. Ft.) (including garage, finished basemenUattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S�UY.M
PUBLIC PROPERTY
DEPARTMENT
KI.O �'4v Nw•n
NtAVa 130 wASONGTON STIM•SALEK NAMLACHMM 01W8
7T1:TW7459S"9 FAx 976-740.9M
HOMEOWNER LICENSE EXEMIMON
Please rrint
Date
Job Location e" i i/cCSonJ S7
Home Owner Address vTa.✓ k��Tr� t
Home Owner Telephone �f/7 Sr- 7 Y/-a 3
Present Mailing Address s c
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she reside@ or intends to reside,-on
which there is, or is intended to be, a one or two family dwellin& attached or detached .
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official.on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeownee certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that el
will comply with said procedures and requirements.
HONEOWYERS SIGYATI. _
APPROVAL OF BUILDING INSPECTOR
See other side for state code
{" CITY OF SALEM
Aka PUBLIC PROPRERTY
DEPARTMENT
I' INtic«rr 4 tine ni, \I,\,; i i I`a -
l'rl: 9,8-74n.9;95 • I .\\: `i'8.174=9846
Construction Debris Disposal At'tidavit
(required liar all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Ch9R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
� I
(name of hauler)
'file debris
will
be disposed of in
(name of facility) O
(address of I'acilicv)
signatmc of permit applicant
dace